Claim Adjustment Reason Code 69 – Day Outlier Amount

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Claim Adjustment Reason Code 69 “Day Outlier Amount”

 

Understanding Claim Adjustment Reason Code 69 – Day Outlier Amount

An outlier payment is an additional form of reimbursement made to the 60-day case mix–adjusted episode payments. It is applied for beneficiaries who incur unusually large costs due to requiring supplementary services to meet their care needs.

For the provider to be eligible, imputed episode costs must exceed the payment rate by 0.67 times the standard base payment amount (a portion of which is adjusted for local wages), Griffin adds. Episode costs are imputed by multiplying the estimated national average per-visit costs by the type of visit (which is adjusted to reflect local input prices) by the number of visits by type during the episode.

“When the estimated costs exceed the outlier threshold, the HHA receives a payment equal to 80 percent of the difference between the episode payment with the threshold and the episode’s estimated costs. This is paid on the final payment to agencies,” explains Griffin. “If an agency hopes to achieve a healthy bottom line, it must eliminate outliers from the category of revenue boosters. Except for a few rare instances, outlier payments seldom bridge the gap between costs and profits.”

Outlier Threshold:

The upper range (threshold) in length of stay before a client’s stay in a hospital becomes an outlier. It is the maximum number of days a client may stay in the hospital for the same fixed reimbursement rate. The outlier threshold is determined by the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA).

Cost outlier — an inpatient hospital discharge that is extraordinarily costly. Hospitals may be eligible to receive additional payment for the discharge. Section 1886(d)(5)(A) of the social security act provides for Medicare payments to Medicare-participating hospitals in addition to the basic prospective payments for cases incurring extraordinarily high costs.

Timetable for coding inpatient cost outlier claims:

Cost outlier -an inpatient hospital discharge that is extraordinarily costly. Hospitals may be eligible to receive additional payment for the discharge. Section 1886(d)(5)(A) of the social security act provides for Medicare payments to Medicare-participating hospitals in addition to the basic prospective payments for cases incurring extraordinarily high costs.

  • To qualify for outlier payment, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments to qualify for outliers).
  • Total covered charges for an inpatient admission are $100,000 (hospital costs)
  • The prospective payment system (PPS) threshold amount for the DRG is $65,000 (fixed-loss threshold amount)
  • CMS publishes the outlier threshold amounts in the annual inpatient prospective payments system (IPPS) final rule. Providers may access CMS’ website to download the IPPS pricer.

Inlier — a case where the cost of treatment falls within the established cost boundaries of the DRG payment. To determine if the inpatient hospital claim meets the criteria for cost outlier reimbursement, two pieces of information are needed: 1) total covered charges and 2) PPS threshold amount. If the total covered charges exceed the PPS threshold amount, follow the coding rules for inpatient cost outlier claims.

DRG cutoff day — the “To” date or “End” date of the inlier period. Once the PPS threshold amount is known add the daily covered charges incurred by the patient until determining the day that covered charges reach the cost outlier threshold amount. Exclude days and charges during non-covered spans (e.g., occurrence span code 74 [non-covered level of care], 76 [patient liability], 79 [payer code] dates).

Occurrence code (OC) 47 — a code that indicates the first day the inpatient cost outlier threshold is reached or the date after the DRG cutoff date. For Medicare purposes, a beneficiary must have regular coinsurance and/or lifetime reserve days available beginning on this date to allow coverage of additional daily charges for the purpose of making cost outlier payments. OC47 date cannot be equal to or during dates coded for occurrence span code 74, 76, or 79.

Occurrence code A3 — (Benefits exhausted) the last date for which benefits are available and after which no payment can be made.

Occurrence span code 70 — a code and span of time that indicates the from and through dates during the PPS inlier stay for which the beneficiary has exhausted all regular days and/or coinsurance days, but which is covered on the cost report.

Condition code 61 — a code that indicates this bill is a cost outlier.

Condition code 67 — a code that indicates the beneficiary has elected not to use lifetime reserve (LTR) days.

Condition code 68 — a code that indicates the beneficiary has elected to use lifetime reserve (LTR) days.

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